Basic Information
Provider Information | |||||||||
NPI: | 1043696420 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | NORDBY | ||||||||
FirstName: | STEFANY | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 712 S CASCADE ST | ||||||||
Address2: |   | ||||||||
City: | FERGUS FALLS | ||||||||
State: | MN | ||||||||
PostalCode: | 565372913 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2187368000 | ||||||||
FaxNumber: | 2186857296 | ||||||||
Practice Location | |||||||||
Address1: | 1411 HIGHWAY 79 E | ||||||||
Address2: |   | ||||||||
City: | ELBOW LAKE | ||||||||
State: | MN | ||||||||
PostalCode: | 565314645 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2186857300 | ||||||||
FaxNumber: | 2186857296 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/07/2015 | ||||||||
LastUpdateDate: | 02/17/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 2311 | MN | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
ID | Type | State | Issuer | Description | 2311 | 01 | MN | MN BOARD OF MEDICAL PRACTICE | OTHER |